Balloting is under way at standards development organization Health Level Seven on the first set of what will be a battery of document transmission standards being worked up for the movement of dictated and transcribed text-based patient information.
Implementation guides for documents containing 'history and physical reports' were submitted Monday to Ann Arbor, Mich.-based HL7. It is the first ballot in what is expected to be a series of interoperability specifications under a project called Clinical Document Architecture for Common Document Types, or CDA4CDT.
Coming later under the CDA4CDT effort will be guides for physician consults, operative notes, subjective, objective, assessment and plan notes, and radiology reports, said Harry Rhodes, director of practice leadership for the American Health Information Management Association, the Chicago-based association for medical records professionals and one of several original project sponsors.
"We're going to release multiple implementation guides and there will be one (balloting) for each of the types," Rhodes said. The history and physical report was the first guide chosen for preparation to ballot because the H&P is the most common document across all care sites, according to Rhodes. "Every consultation takes pieces of the H&P and puts it in there as well, so we thought it was a good foundational document. We haven't decided which one will be next."
Standards development expert Liora Alschuler, the CDA4CDT project leader, said balloting is the least of the worries ahead.
"The first challenge is to get this adopted," Alschuler said. "We have high hopes that this will see relatively rapid, widespread adoption because it has a really minimal impact on workflow. If it overcomes that challenge and providers do adopt this, if physicians are dictating to this requirement, then transcription companies will be outputting CDA documents.
"So what does that do for humanity? If we look at building interoperability and patient-centered records, this is the largest single gain in interoperability that the industry could see," Alschuler said. "Most information in a chart comes through a voice interface in most institutions. This has the potential to be the great leap forward in terms of interoperability."
Having interoperable information could trigger an IT "chain reaction," Alschuler said. "It makes all these networks viable. The networks need data. This gives us a critical mass of interoperable data of varying degrees of computability. The networks will start to have an economic model and we'll see a definite, gradual rise then in the amount of records that are computable."
At their lowest level of computability, dictated and transcribed documents that are in conformance with the CDA4CDT standards will have a standardized CDA header, "which allows you to find that document, put it into a document management system and to classify it as to the type of data and the provider and the patient," Alschuler said. "In terms of the report itself, the body must be in a minimal conforming XML and it must have the required sections, which is itself a big advance in consistency of practice. And the sections have to carry a LOINC (Logical Observation Identifiers Names and Codes) code to tell you what exactly it (each section) is, such as a history of present illness.
"This isn't a silver bullet," she said. "It won't drive decision support, but just having them in XML, knowing what section things are in allows, knowing where it starts and ends, allows some automation."
For example, a history-of-present-illness section might be grabbed electronically and reused in developing a discharge summary, Alschuler said.
She said more than a half dozen of the sections in the new H&P guide are the same as and therefore compatible with sections defined for the Continuity of Care Document, a compromise standard balloted successfully by HL7 earlier this year. The CCD adapts the Continuity of Care Record developed by ASTM International to the CDA from HL7.
Finally, many transcription service providers are either using or experimenting with speech recognition systems that may one day capture specific, computable data elements from dictation sound files.
"Just having it in XML and knowing reliably that it is a family history section is a huge leg up for natural language processing," Alschuler said. "It really helps them."
AHIMA's Rhodes agrees, though, realizing all of these benefits depend on on providers using the guides once they are voted on.
"The problem is, right now, if you are a computer system and you're looking at a dictated, transcribed report, it’s not computable," Rhodes said. "There is just this blank space there. A lot of facilities put headers and footers on their documents, but those are unique to the organization and sometimes within the organization, they may all use different header and footer formats. Inside the record, I can't think of anyone who uses formats so that it's computable and you can use searches to find it.
"Our goal is to enlarge and enrich the flow of data between healthcare providers," he said. "Before, when you wanted to find out what was in a report, you had to call it up and read it. We're hoping the structure will speed the development of interoperable document repositories and speed the use of information for health information exchanges and will increase the amount of data that is available in those exchange networks."
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